Understanding Liver Cancer

Liver cancer arises when cells within the liver mutate and grow uncontrollably. The liver is a vital organ responsible for filtering toxins from the blood, producing bile to aid digestion and helping to regulate metabolism. Globally, liver cancer is one of the most commonly diagnosed cancers.

In Singapore, liver cancer remains a significant health burden. According to the Singapore Cancer Registry Annual Report 2023, it is the fifth most common cancer in males and one of the top five leading cause of cancer-related deaths in both men and women.

At the National Cancer Centre Singapore (NCCS), liver cancer care is built on thorough clinical evaluation and multidisciplinary planning to ensure each patient receives tailored treatment. Below we explore what liver cancer is, how it is detected and assessed, the treatment options available, and the comprehensive support offered throughout the care journey.

What Is Liver Cancer

Liver cancer develops when liver cells undergo genetic changes that cause them to grow and multiply in an uncontrolled manner. Over time, these abnormal cells can form a tumour and interfere with normal liver function.

Liver cancer may be classified as primary or secondary: 

• Primary liver cancer begins in the liver itself. 
• Secondary (metastatic) liver cancer occurs when cancer from another part of the body (e.g the colon or lung) spreads to the liver.

This article focuses on primary liver cancer, which is less common than secondary liver cancer.

Types of Primary Liver Cancer

Hepatocellular Carcinoma (HCC)

Hepatocellular carcinoma is the most common type of primary liver cancer. It arises from hepatocytes, the main functional cells of the liver. HCC often develops in the setting of chronic liver disease or liver scarring (cirrhosis).

Cholangiocarcinoma

Cholangiocarcinoma is a cancer of the bile ducts, which carry bile from the liver to the small intestine. When it arises within the liver, it is known as intrahepatic cholangiocarcinoma. This type of liver cancer behaves differently from HCC and may require different treatment strategies.

Less Common Liver Tumours

Less common liver tumours arise from specialised or less abundant cell types:

• Hepatoblastoma develops from immature liver cells that are present mainly during early childhood. Because these cells are not found in significant numbers in adults, hepatoblastoma is rare and occurs almost exclusively in young children. 
• Angiosarcoma arises from the cells lining blood vessels within the liver. These cells make up only a small portion of liver tissue, and cancerous changes in them are uncommon. In some cases, angiosarcoma has been linked to exposure to specific chemicals, which are rare in the general population.

Symptoms of Liver Cancer

In its early stages, liver cancer may cause few or no symptoms. As the disease progresses, symptoms may develop and can include:

• Persistent abdominal discomfort or pain, particularly in the upper right abdomen 
• Unexplained weight loss or loss of appetite 
• Fatigue or weakness 
• Abdominal swelling due to fluid accumulation 
• Yellowing of the skin or eyes (jaundice) 
• Nausea or early fullness after eating small amounts

These symptoms can also be caused by non-cancerous liver conditions. Any persistent or worsening symptoms should be assessed by a doctor for appropriate evaluation.

Causes and Risk Factors for Liver Cancer

Liver cancer most commonly develops from long-standing liver injury or inflammation. Repeated damage to liver cells increases the likelihood of genetic changes that can lead to cancer.

Non-modifiable Risk Factors

• Chronic hepatitis B or hepatitis C infection 
• Liver cirrhosis from any cause 
• Certain inherited liver conditions 
• Increasing age

Modifiable or Lifestyle-Related Factors

• Excessive alcohol consumption leading to liver damage 
• Non-alcoholic fatty liver disease related to obesity or diabetes 
• Smoking 
• Exposure to certain toxins or chemicals

Having one or more risk factors does not mean a person will develop liver cancer, but it may increase overall risk.

How Liver Cancer Is Diagnosed

Diagnosis of liver cancer involves a combination of imaging tests, blood investigations and, in some cases, tissue sampling. These tests help confirm the presence of cancer and determine its characteristics.

Imaging Tests

Imaging plays a central role in diagnosing liver cancer and may include:

• Ultrasound of the liver 
• Contrast-enhanced CT scans 
• MRI scans to assess tumour size, number and blood supply

These tests help doctors distinguish liver cancer from benign liver nodules and assess whether surrounding structures are affected.

Blood Tests

Blood tests may assess:

• Liver function 
• Alpha-fetoprotein (AFP), a tumour marker blood test that can be elevated in some liver cancers 
• Overall health and suitability for treatment

Biopsy

In selected cases, a biopsy may be required to confirm the diagnosis. A small sample of liver tissue is examined under a microscope to identify cancer cells and determine tumour type.

Staging and Classification

Liver cancer staging considers both the extent of the cancer and the underlying health of the liver. This is important because liver function strongly influences treatment options.

Assessing Tumour Extent

Doctors assess:

• The size and number of tumours 
• Whether blood vessels are involved 
• Spread to nearby lymph nodes or distant organs

Because many patients with liver cancer also have chronic liver disease, staging systems take liver function into account. Tests evaluate how well the liver is working and whether it can tolerate certain treatments.

Why Staging Matters

Staging helps guide treatment decisions, estimate prognosis and determine whether curative or disease-controlling approaches are most appropriate. Patients are encouraged to discuss what their stage means for their individual situation with their care team.

Treatment for Liver Cancer

Liver cancer treatment is tailored to the individual and guided by a multidisciplinary team at NCCS. Treatment depends on:

• Cancer stage and tumour characteristics 
• Liver function 
• Overall health 
• Patient preferences, where appropriate

Surgery

Surgery may be an option for patients with early-stage liver cancer and well-preserved liver function. This may involve removing part of the liver containing the tumour.

Localised Therapies

Local treatments target tumours within the liver and may include:

• Radiofrequency or microwave ablation 
• Transarterial chemoembolisation (TACE) 
• Radioembolisation

These approaches may be used when surgery is not suitable.

Systemic Therapy

Systemic treatments include targeted therapy and immunotherapy. These medicines circulate throughout the body and may be used for more advanced liver cancer or when local treatments are not appropriate.

Radiation Therapy

Advanced radiation therapy techniques may be used in selected cases to control tumour growth or relieve symptoms.

Liver Transplantation

In selected cases where the cancer recurs or liver disease is advanced, liver transplantation may be considered. This treats both the cancer and the underlying liver disease but requires strict eligibility criteria and careful evaluation.

What Treatment Aims to Achieve

For liver cancer, treatment goals are shaped not only by the stage of the cancer but also by how well the liver is functioning. Because the liver plays a vital role in many bodily processes, treatment plans are carefully designed to balance cancer control with preservation of liver health.

Depending on individual circumstances, treatment may aim to:

• Remove or destroy the tumour in selected patients with early-stage disease and sufficient liver function 
• Control cancer growth and reduce the risk of further spread when curative treatment is not possible 
• Relieve symptoms, such as pain or abdominal discomfort, caused by the tumour 
• Preserve liver function and quality of life while managing the disease

In some patients, liver cancer can be treated with curative intent through surgery, transplantation or localised therapies. In others, the disease is managed as a long-term condition, with treatment focused on controlling progression and supporting overall wellbeing.

Supportive Care and Living With Liver Cancer

Supportive care plays an important role in the management of liver cancer and may be introduced early, alongside active treatment. Because the liver is involved in digestion, metabolism and detoxification, supportive care focuses not only on comfort but also on maintaining liver function and daily wellbeing.

Support may include:

• Management of liver-related symptoms, such as abdominal discomfort, swelling, fatigue, nausea or itching 
• Nutritional guidance, including advice on protein intake, salt restriction or meal planning to support liver health and manage appetite changes 
• Monitoring and management of fluid build-up in the abdomen or legs, which can occur with reduced liver function 
• Psychological and emotional support to help patients and families cope with uncertainty, lifestyle adjustments and treatment decisions 
• Rehabilitation and nursing support, particularly for those recovering from procedures or managing long-term effects of treatment

Patients are encouraged to discuss symptoms or concerns promptly with their doctor , as early supportive care interventions can improve comfort and quality of life.

Follow-Up and Monitoring

Regular follow-up allows doctors to monitor treatment response, manage side effects and detect recurrence early. Follow-up may include:

• Imaging tests 
• Blood tests 
• Physical examinations

The frequency of follow-up is individualised based on treatment and recovery.

Guidance and Support at NCCS

A diagnosis of liver cancer can be challenging. At NCCS, patients receive coordinated, multidisciplinary care that addresses both medical treatment and overall wellbeing. Clear communication, education and ongoing support help patients and their families navigate diagnosis, treatment and follow-up with confidence.

Patients are encouraged to ask questions, share concerns and take an active role in their care.

For more information about liver cancer or to discuss your treatment plan, please speak with your NCCS care team or visit www.nccs.com.sg.

Commonly Asked Questions

1. Can liver cancer be detected early if I have no symptoms?

Yes. In people with chronic liver disease or hepatitis, regular surveillance with imaging and blood tests can help detect liver cancer at an earlier stage, sometimes before symptoms develop.

2. Does having hepatitis always mean I will develop liver cancer?

No. While chronic hepatitis B or C increases the risk of liver cancer, many people with hepatitis never develop cancer. Regular monitoring and appropriate treatment can significantly reduce risk.

3. Can liver cancer be treated if I also have cirrhosis?

Yes. Treatment options depend on the cancer stage and the liver function. Some therapies are suitable even in the presence of cirrhosis, and care is carefully individualised.

4. Will treatment for liver cancer affect my daily activities?

Some treatments may cause temporary fatigue or other side effects, while others have minimal impact on daily life. Your care team can advise on activity levels and support during treatment.

5. How will my care team decide which treatment is best for me?

Treatment recommendations are made by a multidisciplinary team that considers tumour characteristics, liver function and patient’s overall health. Recommendations are discussed with you so that decisions are shared and informed.